Information Collection

Champus/champva Form 500

IC 165184 under ICR 198509-0704-004 · OMB 0704-0084.

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Information Collection (IC) Details

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IC Title:	CHAMPUS/CHAMPVA FORM 500	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CHAMPUS/				No	No
Form	CHAMPVA 500				No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,706,202	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	3,706,202	206,202	3,500,000
Annual IC Time Burden (Hours)	2,100,181	140,181	1,960,000
Annual IC Cost Burden (Dollars)	0	0	0

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.